Hallmark Manor

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Assess the resident when there is a significant change in condition

Ensure each resident receives an accurate assessment.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure services provided by the nursing facility meet professional standards of quality.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide enough food/fluids to maintain a resident's health.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Provide and implement an infection prevention and control program.

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Respond appropriately to all alleged violations.

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Assess the resident when there is a significant change in condition

Ensure each resident receives an accurate assessment.

PASARR screening for Mental disorders or Intellectual Disabilities

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure services provided by the nursing facility meet professional standards of quality.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide safe and appropriate respiratory care for a resident when needed.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Ensure medication error rates are not 5 percent or greater.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide and implement an infection prevention and control program.

Provide safe, appropriate pain management for a resident who requires such services.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Ensure medication error rates are not 5 percent or greater.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Ensure staff are vaccinated for COVID-19

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

PASARR screening for Mental disorders or Intellectual Disabilities

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.